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Effect of contraception uptake on pregnancy outcomes among young women: evidence from the Indian demographic health surveys

BMC Public Health volume 25, Article number: 1540 (2025) Cite this article

Abstract

Background

Several risk factors contributing to pregnancy outcomes among young women have been witnessed. It is well established that contraception plays a foremost role in reducing maternal mortality, obviously linked to pregnancy outcomes. Little is known about the impact of contraception uptake on pregnancy outcomes in the Indian context. Thus, this paper aimed to examine the effect of type of contraception on pregnancy outcomes among young married women aged 15–24 years.

Methods

Data was extracted from the 2015-16 and 2019-21 National Family Health Survey (NFHS). The main outcome measure was pregnancy outcomes (live birth, abortion, miscarriage and stillbirth). Type of contraception uptake (no contraception, Short-Acting Reversible Contraceptives (SARCs), Long-Acting Reversible Contraceptives (LARCs) and permanent methods) was considered as the key exposure variable. To fulfil the study objective, cross-tabulations, chi-squared tests, and multinomial logistic regression models were employed.

Results

During 2015-16–2019-21, the prevalence of live birth declined by 5.74%, whereas the proportion of miscarriage, abortion and stillbirth increased by 4.87%, 0.79% and 0.06%, respectively. Results from the multinomial models revealed that the association between type of contraception and pregnancy outcomes were strongly significant, even after adjusting for many other potential correlates. The results further found that the likelihood of abortion, miscarriage and stillbirth were significantly lower among young women using SARCs and markedly lower among women using LARCs methods, compared to no contraception use. Besides, women’s age group, body mass index, height, haemoglobin level, parity, antenatal visits, place and mode of delivery, desire for more children, pregnancy intentions, distance to a nearest health facility, education level, social group, wealth quintile place and region of residence were also significantly associated with pregnancy outcomes.

Conclusions

The findings from this paper reinforced the need of the hour for implementing effective policies and adverse pregnancy prevention strategies towards ensuring access to the most effective contraception and underscore the importance of scaling up the quality of family planning services and health education that could lead to achieving the best possible pregnancy outcomes among young women.

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Background

Young women aged 15–24 years are more prone to multiple maternal and childbirth complications than other age groups, which may lead to poor reproductive health and Adverse Pregnancy Outcomes (APOs). Childbearing during young age is not only associated with an increased risk of APOs but also has a negative impact on the future well-being of mothers and infants [1, 2]. Postponement of early childbearing may aid in long-term health benefits for both mother and child. Several studies have reported that young women’s pregnancy is closely linked with an increased risk of worse maternal and perinatal outcomes, including abortion, miscarriage, stillbirth, preterm birth, Low Birth Weight (LBW) and maternal mortality [3,4,5,6,7]. These are mostly caused by biological and psychological immaturity, inadequate maternity services and poor socio-economic status among young women [8,9,10,11,12]. It is estimated that about 12 million adolescents aged 15–19 years give birth in developing regions each year [13]. Despite concerted efforts, adolescent pregnancy is still rampant and one of the most serious public health threats to young women consisting of a range of unfavourable events involving pregnancy and childbirth in many low- and middle-income countries, where both accessibility and utilization of healthcare services are limited. Although India has made considerable progress in reducing the risk of APOs among reproductive-age women during the past few decades, the 2019-21 National Family Health Survey (NFHS) reported that nearly 10% of young women (15–24 years) had experienced APOs (stillbirth, miscarriage, and abortion) in five years preceding the survey, compared with 4.4% in 2015-16 [14]. Thus, there is a need for an immediate endeavour to minimize worse pregnancy events for those young women who do become pregnant.

The aetiologies of APOs are complex and multifactorial, and despite decades of research, a precise mechanism for APOs has not been established satisfactorily. Previous studies have shown that several risk factors are associated with APOs, such as inadequate prenatal or delivery care [15,16,17], abortion [18], anaemia [19,20,21,22,23], obesity [24,25,26,27,28,29], Body Mass Index (BMI) [23, 30,31,32] and many socio-economic factors [32,33,34,35]. Little is known about the consequences of contraception uptake on pregnancy outcomes.

Contraception is a key strategy to improve maternal health through the prevention of unintended and closely spaced pregnancies and reduction in morbidity and mortality. Despite longstanding efforts, the importance of contraception remains low in many low- and middle-income countries, including India. A recent study suggested that most of the Indian young women are unaware of contraception, and even if they are aware, they do not have easy access to or fail to adopt contraception [36]. The lower use of contraception can increase the risk of APOs [37]. A group of studies have found that the adoption of Long-Acting Reversible Contraceptives (LARCs) demonstrates high effectiveness in preventing unintended pregnancy and APOs [38, 39] and better user satisfaction [40] rather than Short-Acting Reversible Contraceptives (SARCs). The latest NFHS-5 reported that, in India, nearly 21% of young women were using SARCs, while only 3.1% were using LARCs in 2019-21 [14]. It is worthy to mention that no contraception increases the risk of pregnancy, which may often lead to APOs. For instance, a study found that adolescents are more likely to experience early, frequent and unplanned pregnancies than younger women (20–24) due to not using contraception and increasing the risk of maternal and infant morbidity and mortality [41]. Inadequate provision of Family Planning (FP) services is a critical concern because contraception is crucial for improving pregnancy outcomes by delaying pregnancy and childbirth as long as necessary.

Although several studies have investigated the effects of potential factors on APOs rather than contraception in India and elsewhere [12, 23, 35, 36, 42,43,44], the role of contraception associated with APOs has largely been understudied [45]. The scarcity of this kind of research is imperative, especially in the Indian context. To shed light on this, this paper aimed to examine the association between type of contraception and pregnancy outcomes (live birth, stillbirth, abortion and miscarriage) among young married women, adjusting for many potential confounding factors using the nationally representative 2015-16 and 2019-21 NFHS datasets. The findings of this paper would contribute to the scanty literature on this subject and identify contraceptive behaviour in the follow-up of pregnancy outcomes. This paper may interest the Maternal Child Health–Family Planning (MCH-FP) program planners for designing and implementing effective policies and targeted health interventions to improve the best possible pregnancy outcomes among young women.

Materials & methods

Data

Data used in the present analyses were derived from the latest two waves of the National Family Health Survey (NFHS), conducted in 2015-16 and 2019-21, respectively [14, 46]. NFHS is a cross-sectional survey conducted in line with the Demographic and Health Survey (DHS). The Ministry of Health and Family Welfare (MoHFW), Government of India (GoI) has designated the International Institute for Population Sciences (IIPS), Mumbai, as the nodal agency for conducting all NFHS survey-related protocols. A two-stage stratified cluster sampling method was adopted by NFHS for the collection of the sample, comprising over 99% of India’s population. The 2015-16 NFHS was conducted in two phases from January 2015 to December 2016 and successfully interviewed a total of 699,686 eligible women aged 15–49 years and 103,525 eligible men aged 15–54 years from 601,509 households with a response rate of 98% and 97%, respectively [46]. Likewise, the 2019-21 NFHS was conducted in two phases from June 2019 to April 2021 and successfully interviewed a total of 724,115 eligible women aged 15–49 years and 101,839 eligible men aged 15–54 years from 636,699 sampled households with a response rate of 98%, 97% and 92%, respectively [14]. A detailed description of the sampling techniques and survey procedures, including methodology, data processing and questionnaires, can be found in the NFHS survey report [14, 46]. The primary objective of each NFHS wave is to provide reliable and up-to-date information on key aspects of demographic, health and nutrition-related parameters at the district, state/Union Territory (UT), and national levels [14, 46].

For the study, the required information related to this paper was obtained from the DHS-based Woman’s Questionnaire [using Individual Recode (IR) file], in which women aged 15–49 years were asked for more detailed information on their reproductive history during five years preceding the survey. To examine the linkage between the type of contraception and pregnancy outcomes, the study population for the present analyses included only currently married young women (15–24 years) who had experienced their last pregnancies ending in a live birth or APOs in five years prior to the survey. Given this criteria, the final analytical sample for the current analysis was restricted to 86,169 (NFHS-4) and 55,143 (NFHS-5) young married women, respectively.

Ethical statement

The ethical approval of the large-scale nationally representative NFHS-4 and − 5 surveys were obtained from the ethics review board of the IIPS, Mumbai, India. These surveys were also reviewed and approved by ICF International Review Board (IRB). Informed written consent for participation in these surveys were obtained from the respondents during the surveys. Each individual’s approval was sought, and then only the interview was conducted. The NFHS-4 and − 5 are anonymous publicly available datasets with no identifiable information of survey participants and accessible upon a granted request from the DHS data repository at https://dhsprogram.com/data/available-datasets.cfm.

Event of interest

To reach the specific goal of this study, pregnancy outcome among young married women who had experienced their last pregnancies ending in a live birth or APOs in five years prior to the survey was considered as the main event of interest. Therefore, it was coded as a categorical variable using the following last pregnancy outcomes categorized into four possible groups: (1) live birth (delivery of a live baby at any gestational age), (2) abortion (pregnancy terminated before 20 weeks of gestation), (3) miscarriage (spontaneous fetal loss before 28 weeks of gestation) and (4) stillbirth (infant die in the womb after 28 weeks of gestation). For the statistical investigation, live birth was treated as the reference category in the present study.

Explanatory variable

Type of contraception was considered as the key exposure variable of interest in this paper. It was constructed using modern contraceptive methods adopted by young married women in five years prior to the survey, such as SARCs, including pills, condoms, injectable hormones and spermicide; LARCs including intrauterine devices (IUDs) and implants; and Permanent Methods (PMs) incorporating male and female sterilization [47]. Users who had not practised any contraception at the time of the survey were also categorized as no contraception. Thus, young married women responding to various types of contraception mentioned above were further clubbed into four categories — no contraception, SARCs, LARCs and PMs.

Control variables

A set of demographic and socio-economic variables were considered as correlates in the analyses of the present study. The selection of these potential correlates were derived based on their availability on the 2015-16 and 2019-21 NFHS datasets [14, 46] and a growing number of research studies on this subject conducted in India and elsewhere [12, 19, 21, 23, 32, 33, 35, 36, 44, 48]. The variables included in the analyses were: place of residence (urban/rural); level of education (illiterate, primary, secondary and higher); religion (Hindu, Muslim, Christian and Others); caste (Scheduled Castes/Tribes [SC/ST], Other Backward Castes [OBC], and others); wealth quintile (poorest, poor, middle, richer and richest); maternal age (15–19/20–24 years); BMI (kg/m2) [thin (< 18.5), normal (18.5–24.9) and overweight and obese (≥ 25.0)]; height (< 145 cm/≥145 cm); haemoglobin level (non-anaemic/anaemic (10.0–12.0 g/dl); number of ANC visits (< 4 times/≥4 times); Place of Delivery [PoD (home/institution)], Mode of Delivery [MoD (normal/C-section)], parity (1, 2 and 3 or more); desire for more children (wanted soon, wanted later and wanted no more); pregnancy intentions (wanted, mistimed and unwanted); distance to health facility (no problem/minor & big problem); exposure to mass media (no/any); and region of residence (north, central, east, north-east, west and south). The descriptive statistics of the selected variables used in this paper were listed in Table 1.

Statistical analysis

Descriptive statistics were used to summarise the nature of variables included in the present study. Bivariate analyses were performed to capture the distributional nature and the prevalence of associations between the type of pregnancy outcome and selected demographic and socio-economic characteristics of young married women. Pearson’s Chi-squared tests were carried out to determine the level of statistical significance of the bivariate associational differences of the study population. In this approach, variables that were significantly associated with the outcome of interest were included in the regression models. To access the effect of type of contraception on pregnancy outcomes among young married women, a series of multinomial logistic regression models were employed using 2015-16 and 2019-21 NFHS data. The analyses were adjusted for other potential correlates, including demographic and socio-economic characteristics. Adjusted Odds Ratios (AORs) and their corresponding 95% Confidence Intervals (CI) were calculated to determine the strength of associations. To measure the differences, we also presented the results from the multinomial logistic regression analyses as Unadjusted Odds Ratios (UORs) with 95% CI, which did not control for other potential correlates. The level of significance was presented by p-values, and variables at p < 0.05 were considered statistically significant. To ensure the accurate representation of the survey results, sampling weights were thus applied in the current analyses [14, 46]. All statistical analyses were performed using Stata/MP version 14.0.

Results

Characteristics of the respondents

Table 1 represents descriptive statistics summarizing the sample distribution of the selected study variables. Regarding type of contraception uptake, the proportion of users who adopted SARCs increased by 6.9%, followed by LARCs (1.0%), while PMs declined by 6.6% during 2015-16–2019-21. Among background characteristics, the majority (over 91%) of women were found between the ages of 20–24 years than 15–19 years. With respect to maternity services during 2015-16 and 2019-21, women who had attended ≥ 4 ANC visits increased by 7%, institutional birth increased by 9%, and C-sectional delivery increased by 6%, respectively. Over three-fourths of the respondents (75.5% in 2015-16 and 78.0% in 2019-21) lived in rural areas. In terms of educational status, in both surveys, the proportion of young women who had attended no formal education decreased by 7.8%, followed by primary education (4.8%), whereas the proportion of respondents who had completed secondary education increased by 8.3%, followed by higher education (4.2%), respectively. With respect to household’s wealth status, about two-thirds of women were in the lowest three wealth quintiles, whereas both richer and richest quintiles remailed stable in surveys. Notably, respondents with respect to their height, haemoglobin level, desire for more children, last pregnancy intentions and religious affiliations remained stable in both NFHS surveys; nearly 87% of women were having height ≥ 145 cm; majority of respondents had anaemia; approximately 91% of respondents reported desire for another child and had wanted pregnancy; and the majority of respondents (82%) affiliated with Hinduism as described in Table 1.

Table 1 Distribution of the selected background characteristics of young married women, India, 2015-16 (n = 60,030) and 2019-21 (n = 33,829)
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Pregnancy outcomes and type of contraception

Figure 1 shows the prevalence of pregnancy outcomes among young married women in India, considering their last pregnancy ended in live or APOs during 2015-16 and 2019-21 surveys. The figure highlighted that although the prevalence of successful pregnancy outcome (live birth) was higher, it declined slightly by 5.7% points, whereas the proportion of undesirable Non-Live Births (NLBs) or unsuccessful pregnancies terminated by abortion (by 0.8%), miscarriage (by 4.8%) and stillbirth (by 0.06%) increased slowly among young women. Furthermore, Fig. 1 illustrates the proportion of various contraceptive methods amongst young married women in India between 2015 and 16 and 2019-21, of which SARCs had climbed sharply by 6.9% points (from 14.5 to 21.4%), followed by LARCs (only 1%, from 2.2 to 3.2%). Users who did not adopt any contraceptive method declined by only 1.2% points, from 68.98% in 2015-16 to 68.8% in 2019-21, respectively.

Fig. 1
figure 1

Percentage of pregnancy outcomes and type of contraception uptake among young married women, India, NFHS, 2015-16 and 2019-21

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Pregnancy outcomes by selected study variables

Table 2 depicts the results of bivariate analyses showing the differentials in pregnancy outcomes among young married women in five years preceding the survey by their demographic and socio-economic characteristics. Overall, the bivariate results reported significant differences in pregnancy events among women who had experienced live birth, abortion, miscarriage and stillbirth during 2015-16 and 2019-21 surveys. In the same time period, nearly 96% and 90% of pregnancies resulted in a live birth in the past five years, and the remaining 6% and 10% of pregnancies were gone through APOs or NLBs as terminated in abortion, miscarriage and stillbirth. From the table, it was found that a positive change in the prevalence of APOs, as the occurrence of miscarriage was five-fold increased (4.87% points), followed by abortion (0.79% points) and stillbirth (0.06% points), respectively.

The prevalence of live birth declined, whereas the rate of abortion, miscarriage and stillbirth increased slowly among young users who had not used contraception, followed by SARCs and PMs over time. Interestingly, the prevalence of live birth and stillbirth increased considerably among women receiving LARCs. Among the background characteristics, unlike live birth, the prevalence of abortion, miscarriage and stillbirth increased significantly across respondent’s age groups between 2015 and 16 and 2019-21 surveys. Similar patterns were also observed with respect to respondent’s height and haemoglobin level. Barring the prevalence of live birth and stillbirth, the rate of abortion and miscarriage increased across BMI (kg/m2), number of ANC visits, PoD, MoD, parity, pregnancy intentions, distance to a nearest health facility, place of residence, education level, caste, wealth status and regions of residence between 2015-16–2019-21 surveys. With regard to level of education, the occurrence of abortion and miscarriage increased slowly (less than 1%) among young women who had no education or illiterate, primary and secondary educated, while the prevalence of live birth and stillbirth declined relatively irrespective of their level of education. Concerning household’s wealth status, for the period 2015–2021, the proportion of miscarriage and abortion decreased by 0.81% and 0.36% points among respondents who had belonged to the poorest quintile, whereas the prevalence of miscarriage and abortion increased by 0.24% and 0.26% points among wealthier women. Furthermore, the occurrence of adverse consequences of pregnancy, mostly abortion and miscarriage, were considerably higher among women aged 20–24 years, BMI’s 18.5–24.9 and ≥ 25.0 kg/m2, height ≥ 145 cm, non-anaemic, delivered institutional birth, children in 1st and 2nd parity, desired to want another child later or no more, unwanted pregnancy, no problem with distance to a health facility, resided in urban settings and belonged to Hindu and OBC communities during 2015-16–2019-21. With respect to region of residence, the prevalence of live birth and stillbirth went down, whereas miscarriage and abortion, were found to be noticeably higher and varied across regions of residence throughout the country.

Table 2 Percentage of pregnancy outcomes among young married women by selected demographic and socio-economic characteristics, India, NFHS, 2015–16 and 2019-21
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Factors determining pregnancy outcomes

The results of the multinomial logistic regression models were presented in Tables 3 and 4 using NFHS-4 and − 5 datasets. In the regression analyses, both UOR and AOR with 95% CI were calculated to better understand the relationship between the type of contraception and pregnancy outcomes. The unadjusted models (UOR) highlighted the contribution of each selected variable on a range of pregnancy outcomes. Conversely, for comparison, the adjusted models (AOR) showed key insights into the changes in the effect of type of contraception on pregnancy outcomes when other potential correlates were controlled.

Abortion

The type of contraception was significantly associated with abortion, even after controlling for a range of potential correlates, suggesting that the strength of association remained the same and highly valuable in explaining the differentials in the likelihood of the risk of abortion in both un/adjusted multinomial models. As unadjusted results were shown in Table 3, users who received SARCs (UOR = 0.84, CI: 0.70–0.81) were less likely to experience abortion than those who adopted no contraception. While the adjusted results revealed that compared with no contraceptive, the risk of abortion was significantly lower among users who had used LARCs (AOR = 0.79, CI: 0.69–0.74). In Table 4, unlike no contraceptive, the risk of abortion was relatively lower among young users who had adopted SARCs (UOR = 0.69, CI: 0.54–0.61). Similarly, the adjusted results found similar evidence as users who adopted SARCs (AOR = 0.74, CI: 0.55–0.67) were less likely to experience abortion.

As illustrated in Tables 3 and 4 (unadjusted models), respondent’s BMI, number of ANC visits, PoD, MoD, desire for more children, pregnancy intentions, distance to a health facility, place of residence, education level, religion, caste, wealth quintile and region of residence were strongly associated with the risk of abortion. In the adjusted model (Table 3), respondents aged 20–24 years (AOR = 1.77, CI: 1.30–2.40), attended ANC ≥ 4 visits (AOR = 1.18, CI: 1.02–1.37), delivered birth in C-sectional mode (AOR = 1.18, CI: 1.07–1.39), wanted child later (AOR = 2.56, CI: 1.91–2.82), received primary education (AOR = 1.77, CI: 1.37–2.27), belonged to poorer quintile (AOR = 1.78, CI: 1.39–2.29) and residing in the North-eastern region (AOR = 1.37, CI: 0.95–1.97) were more likely to have abortion compared with respondents aged 15–19 years, visited ANC < 4 times, delivered normal birth, wanted child sooner, illiterate and living in the Northern region. Conversely, respondents who had institutional birth (AOR = 0.78, CI: 0.64–0.95), 2nd parity (AOR = 0.74, CI: 0.64–0.86), BMI ≥ 25.0 kg/m2 (AOR = 0.99, CI: 0.68–1.13), height ≥ 145 cm (AOR = 0.95, CI: 0.78–1.16), distance to a health facility for minor & big problem (AOR = 0.70, CI: 0.61–0.8), lived in rural areas (AOR = 0.58, CI: 0.5–0.67), affiliated with Muslim religion (AOR = 0.72, CI: 0.57–0.86), belonging to other castes (AOR = 0.97, CI:0.83–1.17), and residing in the Central region (AOR = 0.65, CI: 0.51–0.82) were less likely to experience abortion than those were living in urban areas, affiliated with Hindu religion, non-institutional birth, lower parity, BMI < 18.5 kg/m2, height < 145, no problem with distance to health facility and residing in the Northern region. Furthermore, Table 4 reveals that women aged 20–24 years (AOR = 1.68, CI: 1.19–2.36), BMI ≥ 25.0 kg/m2 (AOR = 1.16, CI: 0.79–1.03), had anaemia (AOR = 1.35, CI: 1.14–1.60), visited ANC ≥ 4 times (AOR = 1.32, CI: 1.11–1.58), C-section (AOR = 1.10, CI: 0.91–1.33), wanted child no more (AOR = 1.74, CI: 1.30–1.96) distance to a health facility for minor & big problem (AOR = 1.17, CI: 0.99–1.38), attended primary education (AOR = 1.80, CI: 1.19–2.72), belonged to the richer quintile (AOR = 1.76, CI: 1.3–2.40), and resided in the North-eastern region (AOR = 2.43, CI: 1.52–3.90) were found to be more likely to the risk of abortion compared with respondents aged 15–19 years, BMI < 18.5 kg/m2, non-anaemic, attended < 4 ANC visits, home delivery, wanted child sooner, no problem with distance to a health facility, illiterate, belonged to the poorest quintile and resided in the Northern region of residence. The results in Table 4 further contradicted that respondents who lived in rural areas (AOR = 0.67; CI: 0.55–0.81), BMI 18.5–24.9 kg/m2 (AOR = 0.96; CI: 0.79–1.17), and Muslims (AOR = 0.49, CI: 0.37–0.66) were less likely to experience abortion than those who resided in urban areas, BMI < 18.5 kg/m2, and affiliated with Hinduism. Regarding wealth status, the adjusted results found that the wealth quintile was strongly associated with abortion. Young women from the middle (AOR = 1.78, CI: 1.39–2.29; Table 3) and richer (AOR = 1.76, CI: 1.30–2.40; Table 4) quintiles were relatively more likely to have abortion compared with those in the poorest quintile.

Miscarriage

Tables 3 and 4 demonstrate that type of contraception remained a key significant factor on the risk of miscarriage, even after adjusting for a range of correlates. In Table 3, the results reported that users of LARCs (UOR = 0.74, CI: 0.52–1.04) were a relatively lower likelihood of experiencing miscarriage compared with those who didn’t use contraception. In contrast, the adjusted results found that, unlike no contraceptive use, miscarriage was relatively lower among users who had used SARCs (AOR = 0.85, CI: 0.74–0.99). Furthermore, the unadjusted results in Table 4 revealed that users who had used SARCs (UOR = 0.41, CI: 0.37–0.45) were less likely to experience miscarriage compared with no contraceptive use. While the adjusted results highlighted that the risk of miscarriage was significantly higher among women who used LARCs (AOR = 0.27, CI: 0.17–0.44) than women who used no contraception. Thus, both un/adjusted results suggested that the strength of association between type of contraception and miscarriage were significantly increased by other potential correlates.

Among the background characteristics, respondents’ age group, BMI, number of ANC visits, desire for more children, level of education, religion, wealth quintile and region of residence were strongly associated with miscarriage in the unadjusted models (shown in Tables 3 and 4). However, the adjusted model (Table 3) found that women aged 20–24 years (AOR = 2.12, CI: 1.65–2.74), BMI ≥ 25.0 kg/m2 (AOR = 1.31, CI: 1.15–1.73), height ≥ 145 cm (AOR = 1.18, CI: 0.98–1.41), C-section (AOR = 1.10, CI: 0.94–1.28), wanted no more child (AOR = 1.29, CI: 0.85–1.53), attended primary education (AOR = 1.25, CI: 1.04–1.51), Muslims (AOR = 1.15, CI: 0.98–1.36) and belonged to the richer quintile (AOR = 1.31, CI: 1.05–1.62) were significantly associated with a higher risk of miscarriage compared with respondents aged 15–19 years, BMI < 18.5 kg/m2, height < 145 cm, wanted child sooner, illiterate, belonged to Hindu and poorest quintile. In contrast, the adjusted results confirmed that respondents who attended ≥ 4 ANC visits (AOR = 0.81, CI: 0.71–0.91), 2nd parity (AOR = 0.47, CI: 0.42–0.54), BMI 18.5–24.9 kg/m2 (AOR = 0.76, CI: 0.58–1.16), highly educated (AOR = 0.64, CI: 0.49–0.84), and resided in the Eastern region (AOR = 0.82, CI: 0.69–0.94) were at lower risk of miscarriage than those who had < 4 ANC visits, 1st parity, BMI < 18.5 kg/m2, non-educated and resided in the Northern region of residence. Moreover, in Table 4, the adjusted results reported that compared with respondents aged 15–19 years, BMI < 18.5 kg/m2 and non-anaemic, women in the age of 20–24 years (AOR = 2.22, CI: 1.66–2.99), BMI ≥ 25.0 kg/m2 (AOR = 1.38, CI: 1.09–1.73), hight ≥ 145 cm (AOR = 1.11, CI: 0.90–1.37), anaemic (AOR = 1.30, CI: 1.13–1.50) were more likely ending with miscarriage. It is needed to be noted that respondents who attended ≥ 4 ANC visits (AOR = 0.89, CI: 0.77–1.02), C-sectional delivery (AOR = 0.77, CI: 0.65–0.93), 2nd parity (AOR = 0.57, CI: 0.48–0.68), distance to a health facility for minor and big problems (AOR = 0.81, CI: 0.71–0.93), lived in rural counterparts (AOR = 0.86, CI: 0.73–1.03), higher educated (AOR = 0.61, CI: 0.44–0.82), affiliated with OBC (AOR = 0.78, CI: 0.67–0.92) and resided in the Western region (AOR = 0.69, CI: 0.53–0.89) were less likely to experience miscarriage compared with respondents who lived in urban places, attended < 4 ANC visits, had a normal delivery, lower parity, no problem with distance to a health facility, illiterate and resided in the Northern region. The adjusted results highlighted that wealth quintile was as a significant factor associated with miscarriage, hinting that the respondents from the wealthier households were relatively more likely to report miscarriage than women in the poorest quintile.

Table 3 Multinomial logistic regression models accessing the association between type of contraception uptake and pregnancy outcomes among young married women (reference category: live birth), India, NFHS, 2015–16
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Stillbirth

Unlike Table 3, the un/adjusted results in Table 4 revealed that the type of contraception use was strongly associated with stillbirth, even after controlling for a range of potential correlates. As unadjusted results were shown in Table 3, young users who had used SARCs (UOR = 0.33, CI: 0.24–0.47) had significantly lower likelihood of experiencing stillbirth compared with no contraception. It is worth mentioning that no significant association was observed between the type of contraception and stillbirth in the adjusted model. In Table 4, the unadjusted results found that compared with no contraceptive use, the risk of stillbirth was significantly lower among users who received SARCs (UOR: 0.29, CI: 0.21–0.40). Conversely, the adjusted results highlighted that users of LARCs (AOR: 0.18, CI: 0.03–0.10) were a lower likelihood of experiencing stillbirth compared with no contraception.

In the unadjusted models (Tables 3 and 4), respondents’ age group, BMI, height, number of ANC visits, PoD, desire for more children, level of education, wealth quintile and region of residence were strongly associated with stillbirth. However, Table 3 shows that respondents aged 20–24 years (AOR = 4.62, CI: 1.86–11.51), BMI ≥ 25.0 kg/m2 (AOR = 1.79, CI: 1.13–2.91), wanted child later (AOR = 1.50, CI: 1.17–1.68), and lived in rural places (AOR = 1.88, CI: 1.23–2.88) were more likely to report stillbirth compared with women aged 15–19 years, BMI < 18.5 kg/m2, wanted child sooner and resided in urban settings. Conversely, young women who had given institutional birth (AOR = 0.48, CI: 0.33–0.71), BMI 18.5–24.9 kg/m2 (AOR = 0.87, CI: 0.63–1.21), height ≥ 145 cm (AOR = 0.74, CI: 0.49–1.14), 2nd parity (AOR = 0.24, CI: 0.16–0.35), distance to a health facility for big and minor problems (AOR = 0.73, CI: 0.53–1.01), received secondary education (AOR = 0.69, CI: 0.46–1.05), affiliated with OBC (AOR = 0.71, CI: 0.51–0.99), belonged to richer quintile (AOR = 1.22, CI: 0.74–2.02) and resided in the Central region (AOR = 0.36, CI: 0.22–0.57) were less likely to report stillbirth than those delivered non-institutional birth, BMI < 18.5 kg/m2, height < 145 cm, lower parity, no problem with distance to a health facility, illiterate, SC/ST, belonged to the poorest quintile and resided in the Northern region. Further, Table 4 found that women aged 20–24 years (AOR = 2.59, CI: 0.95–7.10), BMI ≥ 25.0 kg/m2 (AOR = 2.50, CI: 1.11–5.62) and wanted child later (AOR = 1.02, CI: 0.93–1.12) were more likely to report stillbirth compared with adolescent women (15–19 years) and had BMI < 18.5 kg/m2, wanted child sooner. Besides, women in 2nd parity (AOR = 0.52, CI: 0.3–0.92), height ≥ 145 cm (AOR = 0.49, CI: 0.35–0.55), attended primary education (AOR = 0.11, CI: 0.02–0.64), belonged to the richer quintile (AOR = 0.37, CI: 0.15–0.92) and lived in the Western region (AOR = 0.36, CI: 0.11–1.18) were less likely to report stillbirth compared with respondents in lower parity, height < 145 cm, illiterate, belonged to the poorest quintile and resided in the Northern region.

Table 4 Multinomial logistic regression models accessing the association between type of contraception uptake and pregnancy outcomes among young married women (reference category: live birth), India, NFHS, 2019-21 (31,577)
Full size table

Discussion

India has run several reproductive health care programs to improve the health status of mother and new-born. Despite these efforts, the prevalence of APOs among young women is considerably high as shown in results, leading to an alarming rate of maternal and infant morbidity and mortality. The present study made a first attempt to investigate the association between type of contraception and pregnancy outcomes among young married women using the latest 2015-16 and 2019-21 NFHS datasets. The results indicated that the proportion of abortion, miscarriage and stillbirth increased slightly during 2015-16 and 2019-21 surveys. Although contraception is a basic need, many young women are ignorant of its importance in preventing APOs. As the current findings indicated that a considerable proportion of young women did not uptake any contraception, which becomes susceptible to early or high-risk unintended and closely spaced pregnancies and aggravated risk of APOs. Interestingly, the key finding of this paper showed a strong significant association between type of contraception use and pregnancy outcomes, even after adjusting for a range of potential correlates. The results found that, in both NFHS surveys, respondents who did not use contraception had a higher risk of all three types of APOs compared with those who adopted any kind of contraception. This could be elucidated by the fact that not using contraception has resulted in too early, too many and too close births, which may increase worse pregnancy outcomes [49]. From the findings, it was further observed that the likelihood of all three types of APOs were significantly lower among women using SARCs and markedly lower among women using LARCs methods, compared to no contraception use. Hence, motivating young women to use LARCs could have the potential to reduce the occurrence of APOs or plan future pregnancies. This is also supported by a recent study, where increased use of LARCs may help women to achieve their better reproductive health goals [39]. However, the findings of present study are important because previous research linking the type of contraception to pregnancy outcomes were scarce in the scant literature in the Indian context. The findings provided important context for ensuring access to effective FP services and improving FP counselling and clinical monitoring that can make a positive impact on lowering the risk of APOs and improve maternal health by minimizing the rate of unintended pregnancies among young women in India.

In spite of socio-economic and demographic factors, the importance of contraception use on pregnancy outcomes cannot be ruled out entirely. The results identified that, in both NFHS surveys, women’s age group, BMI, height, haemoglobin level, parity, ANC visits, place and mode of delivery, desire for more children, pregnancy intentions, distance to a nearest health facility, education level, social group, wealth quintile place and region of residence were significantly associated with pregnancy outcomes. These findings are well acknowledged in line with the findings of previous studies on this subject conducted in India and elsewhere [32, 35, 36, 48]. For instance, the results emphasised that women aged 20–24 years had a higher risk of all three types of APOs, and this finding is closely linked with a research study by Fraser et al. [50]. A few studies have found that pregnancy during early age is associated with an elevated risk for APOs [12, 51]. The study findings clearly affirmed that haemoglobin level, BMI and PoD were associated with all three types of APOs, and the results are in accordance with the findings from similar studies [35, 44]. The current results showed that ≥ 4 ANC visits was found to be associated with fewer chances of occurring APOs. This might be due to the fact that mothers who received recommended ANC visits may have access to several maternal health promotion programmes and preventive interventions that improve maternal health and fetus growth, which can eventually reduce the risk of APOs [9, 52]. A noteworthy finding is that education remained as one of the strongest determinants of pregnancy outcomes. Consistent with the current result, an earlier study found that the probability of APOs decreased with an increasing level of education [50]. Unlike the current findings, a few studies have reported that the likelihood of abortion, miscarriage and stillbirth were higher among higher-educated women [12, 36]. The results further reported that the richest quintile was associated with increased odds of having abortion and miscarriage. This finding is corroborated with a similar study conducted in India, in which the risk of APOs increased significantly with each step in the wealth quintile [36]. It is noted that an early start to motherhood may help in reducing educational and employment opportunities and is directly linked to a higher fertility rate [14]. Hence, avoiding early childbearing may allow young women to complete their education to get the benefits of employment opportunities that might contribute to the India’s economic growth by reducing maternal and child health expenditure.

Limitations

The key findings of this paper should be considered in light of the following limitations. The 2015-16 and 2019-21 NFHS provided information on last pregnancies of unmarried, widowed, divorced, separated or all married women irrespective of their reproductive age in five years preceding the survey, but the sample of the present study was restricted to only young married women who had experienced their last pregnancies ending in live birth and NLBs, which may limit the generalisability of the results to all reproductive-age women in India. One of the key limitations is that mothers who died during childbirth were not included in this study, although they would have had the worst APOs. Besides, the study did not include all pregnancies in the current analyses, including those that resulted in multiple births, because it may be possible that some of the pregnancies that did not result in live births had multiple fetuses, but the large-scale NFHS data did not provide any such information regarding the same. Furthermore, the NFHS data were not used for describing the cause-effect relationships between pregnancy outcomes and its driving forces because of the cross-sectional nature of the survey design. Due to limitations in the scope of the database, further research is needed to understand the plausible mechanisms behind the occurrence of APOs among young women in India using longitudinal survey data. The NFHS-4 and − 5 are subject to recall bias in the selection of the study sample. The analyses of this paper were reliant on NFHS-based self-reported data using women’s questionnaires rather than the hospital or clinically recorded data on pregnancy-related events, the definitions of pregnancy outcomes may have lower validity for estimating the prevalence of clinically relevant conditions [53]. Despite these limitations, this nationwide study could be helpful for appropriate policymaking and implementing targeted interventions to boost access and use of FP services in order to improve pregnancy outcomes in India. Further research is needed to take into account a wide range of community- and facility-level confounding variables that may influence the type of pregnancy outcomes among young women. Besides, the effect of type of contraception use on preterm birth, LBW, small-for-gestational-age and perinatal outcomes should be subject to future research to comprehensively analyse the risk of APOs among young women. In addition, the effect of women’s schooling, employment and wealth status on pregnancy outcomes among young women should be considered for further research in Indian context.

Conclusion

The nationwide prevalence of miscarriage was more prevalent than abortion and stillbirth among young married women during 2015-16 and 2019-21 surveys. The findings clearly showed that the type of contraception use was strongly associated with pregnancy outcomes, even after adjusting for a range of potential correlates. Thus, the findings of this study reinforced an inescapable need of the hour for implementing effective programs and strategies toward strengthening and outreach MCH-FP services in imparting knowledge and awareness about the need for multiple forms of contraception, FP services, and efficacy for achieving better reproductive health goals, especially paying particular attention to the socio-economically disadvantaged young women in India. A concerted effort should also be made to underscore the importance of scaling up the adoption of FP services (SARCs and LARCs) in a timely manner and proper MCH-FP counselling during each maternity visit to minimize the risk of unintended pregnancy and APOs amongst young women. Furthermore, several health interventions and adverse pregnancy prevention strategies are imperatively needed for expanding pre-pregnancy care, ensuring access to effective contraception, improving the quality of MCH-FP services, enhancing the public facility-based delivery and improving the level of education as well as health education among young women that could eventually lead to achieve the best possible pregnancy outcomes and to improve the health status of both mother and child survival. In addition, health planners and policymakers should predominantly focus on designing and implementing effective health interventions towards addressing APOs and ensuring optimal birth spacing, which would undoubtedly be the most effective mechanism in reducing undesirable pregnancy outcomes among young married women in India.

Data availability

Data used in the current analysis is publicly available and can be obtained from the Demographic Health Survey (DHS) data repository through https://dhsprogram.com/data/available-datasets.cfm. and could be accessed upon a data request subject to non-profit and academic interest only. The data that supported the findings of this study are available from the corresponding author (MB) upon reasonable request.

Abbreviations

APOs:

Adverse Pregnancy Outcomes

LBW:

Low Birth Weight

BMI:

Body Mass Index

NLBs:

Non-Live Births

LARCs:

Long-Acting Reversible Contraceptives

SARCs:

Short-Acting Reversible Contraceptives

PMs:

Permanent Methods; IUDs: Intrauterine Devices

MCH-FP:

Maternal Child Health–Family Planning

MoHFW:

Ministry of Health and Family Welfare

GoI:

Government of India

DHS:

Demographic and Health Survey

NFHS:

National Family Health Survey

UT:

Union Territory

IIPS:

International Institute for Population Sciences

IRB:

International Review Board

OBC:

Other Backward Castes

SC/ST:

Scheduled Castes/Tribes

AORs:

Adjusted Odds Ratios

UORs:

Unadjusted Odds Ratios

CI:

Confidence Interval

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Acknowledgements

The author is grateful to the Demographic and Health Survey (DHS) Program for providing the dataset in this study. The author is also like to thank anonymous reviewers for their critical inputs in this paper.

Funding

The author did not receive any funding or grant to conduct this specific study.

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Authors and Affiliations

  1. Centre for the Study of Regional Development (CSRD), Jawaharlal Nehru University (JNU), New Delhi, 110067, India

    Monirujjaman Biswas

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Contributions

MB conceptualized and designed the research study, compiled the data, performed the data analysis and prepared the first draft of the manuscript. MB extensively reviewed and edited the first draft and approved the final manuscript. This manuscript is a part of MB’s Ph.D. work.

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Correspondence to Monirujjaman Biswas.

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Ethics approval and consent to participate

The data is freely available in the public domain and survey agencies that conducted the field survey for the data collection have collected prior consent from the respondents. But informed consent was obtained from all study participants in times of surveys, including both illiterate and minor participants. The local ethics committee of the International Institute for Population Sciences (IIPS), Mumbai, ruled that no ethical approval was required for conducting the present research study from this data source. All methods used in this study were carried out in accordance with relevant guidelines and regulations.

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Not applicable.

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The authors declare no competing interests.

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Biswas, M. Effect of contraception uptake on pregnancy outcomes among young women: evidence from the Indian demographic health surveys. BMC Public Health 25, 1540 (2025). https://doiorg.publicaciones.saludcastillayleon.es/10.1186/s12889-025-22811-3

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Keywords

BMC Public Health

ISSN: 1471-2458

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